RENAL ARTERY STENOSIS

 

October 30, 2021

 34 YEAR OLD MALE MASON BY OCCUPATION CAME TO THE OPD WITH 


C/O Blurring of vision RE greater than LE since 3 yrs not associated with headache ,nausea , vomiting




Patient was apparently assymptomatic 3 yrs back ,while he was doing his work complained of giddiness and fell( black outs)non postural,not associated with nausea, vomitings,vertigo,tinnitus,earfull ness ,he was taken to a local hospital and was diagnosed with HIGH BLOOD PRESSURE ( used medication , unknown) for over 2 1/2 yrs 




C/O slurring of speech since 1 year ( progressive) 




C/O body pains since 1 year 




H/O giddiness 1 week back taken to local hospital ,was on medication ( unknown) 




No C/O chest pain , palpitations, shortness of breath ,pedal edema 




K/C/O HTN since 3 yrs (on past atenolol 50mg ,nicardia 10 mg,telma 40 mg)




Not a K/C/O DM,ASTHMA, EPILEPSY,TB




He is alcoholic (90ml /day)and smoker ( 2 per day)since 10 yrs 




No significant family history 




Vitals on admission:


BP: 270/140 mm hg 


 given Nicardia 20 MG and measured bp after 20 mins still the Bp was 270/140 mm hg 


PR : 90bpm


RR: 18 cpm




All the peripheral pulses present 


Ankle brachial index > 1.25 


Renal bruit present


BP:


         RT LT


UL 160/100 170/100


LL 200 200




Cvs : s1s2 + no murmurs


RS : Nvbs +


P/a : soft nontender


CNS : 


1) HMF - INTACT 




2)MOTOR SYSTEM : 


                      Right Left


Bulk: 


Inspection. N. N


Palpation. N. N


Tone: 


UL. N. N


LL. N. N




Upper Limb:


Shoulder: Flexion 5/5. 5/5


Extension. 5/5. 5/5 


Abduction: 5/5. 5/5 


Adduction: 5/5. 5/5 


Elbow: 


Flexion (biceps) 5/5. 5/5 


Extension (triceps) 5/5. 5/5


Lower Limb:


Ilio psoas. 5/5. 5/5


Gluteus max. 5/5 5/5


Adductor femoris. 5/5 5/5


Hamstrings. 5/5 5/5


Quadriceps. 5/5 5/5


Tibialis ant. 5/5 5/5


Tibialis post. 5/5. 5/5


Ex. Digitorum L. 5/5. 5/5 


Fl. Digitorum L. 4/5. 4/5


Ex. Hallucis L. 4/5. 4/5


Deep tendon reflexes:


Biceps: +2 +2


Triceps: +1 +1


Supinator: +2 +2


Knee: +3 +3


Ankle: +3 +3


Plantar: extensor flexor




Sensory:


STT: Crude touch. + +


Pain. + +


Temp. + +


Post. Dorsal


Fine touch. present


Vibration. + +


Position. + +




Cranial nerves : 


II - Blurring if vision present - Rt side > left side.


Visual acuity - Right side - only PL/PR present.


and hand movements perceived . Cant count fingers.


Left side - Counting fingers 3 m present.




III,IV,VI - Extra-ocular movements intact




ii) Pupil – Size - 4 mm - B/L NSRL




iii) Direct Light Reflex - Present.




V - i) Sensory -over face intact




ii) Motor – masseter, temporalis, pterygoids 




iii) Reflex




a. Corneal Reflex - present




b. Conjunctival Reflex - present




c. Jaw jerk - present.


VII - Slight deviation of mouth to left side .


IX ,X- Uvula deviated to right side .


Gag reflex intact.




XI, -normal


XII - no deviation of tongue .





CEREBELLUM : Heel knee test - normal


Finger nose couldn't be performed because of blurring of vision .


Horizontal Nystagmus present . Fast component to left side .


Couldn't perform Tandem gait .




Bp - Unequal in both arms .


All peripheral pulses felt and no asymmetry noted.




Cause for his renal artery stenosis?


could it be ? takayasu arteritis .


ACR criteria - for Takayasu arteritis .(in out pt)


1)Age of 40 years or younger at disease onset - present.


2)Claudication of the extremities - absent 


3)Decreased pulsation of one or both brachial arteries - absent ( equal on both sides )


4)Difference of at least 10 mm Hg in systolic blood pressure between arms - Present .


5) Bruit over one or both subclavian arteries or the abdominal aorta - absent over subclavian. heard over renal artery .


6)Arteriographic narrowing or occlusion of the entire aorta, its primary branches, or large arteries in the upper or lower extremities - 

We dont have evidence yet . have to get CT ANGIOGRAM done .


Diagnosis : HYPERTENSION SECONDARY TO RIGHT RENAL ARTERY STENOSIS WITH


GRADE IV HYPERTENSIVE RETINOPATHY WITH


RENAL ARTERY STENOSIS SECONDARY TO ? VASCULITIS ? TAKAYASU ARTERITIS WITH


LVH WITH RIGHT FACIAL PALSY WITH SLURRED SPEECH WITH DENGUE FEVER NS1 POSITIVE


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